0704 (BLCK)PERMIT APPLICATION
City of La Ouinta
Department of Building and Safety
This.permit becomes void if work not commenced within, 180 days from date of
issuance, OR, it work has been suspended or. abandoned fora, period of 180 days. ••
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CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if .,
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under, provisions of Chapter 9
the•permit is for one hundred ($100) o• less. I certify that in the performance of the work for which this permit is
• -,(commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force
issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of
and effect.
California.
License Class Lic. Number.
Date Applicant
' Date Contractor •
NOTICE TO APPLICANT: If, after making this Certificate of. Exemption, you should become subject to the Workers'.
OWNER -BUILDER DECLARATION:• I hereby affirm that I am exempt from the Contractor's License Law for the
Compensation ,provisions, of the Labor Code, you must forthwith comply with such provisions or this'permit shall
following reason (Sec. 7031.5. Business and Professions Code: Any city or county, which requires a permit.to
be deemed revoked.
construct, alter, improve. demolish, or repair any structure, prior to its issuance, also requires the applicant for
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law
0 hereby certify that no excavation five (5) or mom fe6t in depth into which a person is required to descend, will be
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code) or that he is exempt...
made in connection with work authorized by.this permit, and that no buildinD structure. scaffolding. falsework, or
therefrom and the, basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a'permit. ,
demolition or dismantling thereof, will be more than thirty-six (36) feet high, (Chap 3.2, Grp 2, Art 2, Sec341, Title B,
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
C.A:C')I• ' - I • ' t
❑ 1, as owner.ol the property, or my employees with wages as their sole compensation, will.do the work, and the
'0 As owner -builder,- I will not employ anyone to do work Which -would require a permit from the Division of
structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License
Industrial Safety, as noted -above, unless such person has a permit to do such work from that division.
r Law does not apply. to an owner of property who builds; or improves thereon, and who does such work himself or
it
through his own employees, provided that such improvements are not intended,or offered for sale. If, however, the
❑. Division of Industrial Safety Permit.No.
_building orimprovemntissoldwithinone year ofcompletion, the owner -builder will have the burden of proving that
..Date ' .Applicant. '
he, did not build or improve for the purpose of sale.).
,`.'a°�
CONSTRUCTION LENDING AGENCY: .1 hereby affirm that there is a constructiori lending agencyfor the performance '
0. I.:as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec:
ofthe work for -which this permit is issued (Sec. 3097; Civ. C.).
7044. Business and Professions Code: The Contractor's License Law does not apply to an owner of property who
Lender's Name
builds or improves thereon. and'who contracts for such projects with a'contractor(s) licensed pursuant to.the
- - .-
_ Contractor's License Law.).
Lender's Address -
❑ 1 am exempt under Sec. B. 8 P.C.;(Attached Certificate).
I certify that I have readthis application and state that the above information is correct. ) agree to comply -with all
Date Iowner ;'
city and county ordinances and state laws relating to building construction, and -hereby authorize representatives
of this county to enter upon the above-mentioned property for inspection purposes.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or a
certificate of Workers' Compensation Insurance . or a certified copy thereof (Sec. 3800. Lab. C.).•
Signature of Applicant or Agent Date
Policy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify l have read this application and state that
❑ Certified copy is hereby furnished.
-the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
O Certified copy is filed with the City Building Inspection Department or City Department.
• . -
construction, and authorize.a;representative of the City of La Ouinta Department of Building and Safety to enter -
upon the propeiiy for.which.I i&e applied for this permit for the purpose of making inspections.
Date Applicant
,•
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Signature of Applicant or Agent Date
APPLICANT NAME (L. F. MI)'
ADDRESS
CITY/COMMON ITY/STATE/ZI P
JOB SITE AOOOREESS%SVACE
CITY/COMMUNITY/STATE/ZIP ,
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TRACT NAME - r
OWNER NAME (L. F. MI) ...���� -
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CONTRACTOR -FIRM NAME
ADDRESS -
CITY/COMMUNITY/STATE/ZIP' '-
PHONE • /
•NAAAME
LICNC 0-
ARC/ENG //ENGG FFIRM
ADDRESS
CITY/COMMUNITY/STATE/ZIP I
PHONE 0
LICNC 1
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city— I
USE OF PERMIT
BL
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SSB..•.RSB
1 Fqp �
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ZONE ORD N.'
- LOT SZ '-
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END •
SIDE,
TOTAL
FEE
Print Applicant/Agent Name
APPL/PRMTnzn4
DATE
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TOTAL
FEE
BLDG. DEPT. VALUATION
J
NO.
OPERATION DATE
INSPECTOR
NO. OPERATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33 Ventilation System
2
Ftgs & Frms
34 Plenums & Ducts
2A
Slab Grade
35 Furnace Compart.
3
Steel
36 Inlets & Outlets
4
Grout Blocks
37 Combustion Air
5
Bond Beams
38 Compressor
6
Roof Deck
39 Appl. Clearance
7
Framing
40 Fire Damper
8
Vents
41 Smoke Detection Device
9
Garage- Fire Wall
42 Commercial Hood
10
Fireplace P. L.
❑
43 Final
10A
fireplace T.O.
❑
NON ADDITIONAL INFORMATION
F✓/2" '"awl 1o2i3/ �����
SEWAGE SYSTEM SIZE'& LOCATION
11 Exterior Lath
12 Internal Lath
,12A Drywall
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
12B Ceiling (Batts)
12C Ceiling (Blown)
14 Final
PLUMBING APPROVALS
15 Ground Plumb
16 Water Piping
17 Rough Plumb
18 Vents
19 Sewage Disposal
20 Sewer
21 Water Heater
22 Water Softener
23 Water Service
24 Gas Test
25 Final
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
PSL P/I
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final